Psychological disturbances encountered by the healthcare professionals, military professionals and general public in Sri Lanka during COVID-19 pandemic: a cross-sectional study | BMC Psychiatry

The study observed a greater level of anxiety and depressive symptoms among frontline HCWs and military professionals in Sri Lanka during the pandemic of COVID-19. The general public experienced less anxiety and depressive symptoms when compared to those professionals.

Similar to the finding of HCWs experiencing high levels of depressive symptoms and anxiety, studies done elsewhere also reported consistent findings. A Sri Lankan study conducted with HCWs revealed that 53.3% experienced elevated depressive symptoms while 42.2% experienced mild anxiety, 6.6% with moderate anxiety, and 2.5% with severe anxiety owing to fear of being infectious, spreading to family members, occupational insecurity, and defamation [13]. A review highlighted that during the COVID-19 pandemic, higher level of depression, anxiety, and stress had been reported among non-front line HCWs compared to frontline HCWs, and both groups had higher levels of psychological illness when compared to the general people around the world [4]. De Boni et al. [17] reported that frontline HCWs from Brazil and Spain, highly suffered from depression and anxiety (26.7% of depression, 39.6% of anxiety and 35.4% of both conditions). An Indian study reported a higher prevalence of stress, anxiety, depression, and psychological distress among HCWs compared to the general population [18]. Similarly, a Chinese study reported high level of depressive symptoms among HCWs [19].

HCW’s were the backbone of the COVID-19 prevention and management campaign in Sri Lanka. Their frontline work role could have been contributed for observing more depression and anxiety among them. Apart from that, heavy workload with long duty hours, exhaustion, compulsory quarantine rituals, strict hygienic measures, frequent contact with infected cases, fear of transmission of disease to family members, illness or death of close friends and colleagues, lack of rest and leave and personal isolation associated with COVID-19 may have caused anxiety and depressive symptoms among them. Frontline nurses in several countries, such as India, America, Spain, Australia, and China, also reported of depression due to anxiety and fear of infection, exhaustion because of working for long hours without proper nourishment, lack of medical supplies and resources such as personal protective equipment and lack of communication with patients [20]. A review reported that HCWs verbalized that they had to cope with different psychological challenges, including anxiety, depression and insomnia, due to COVID-19 causing a heavy toll and being affected by different factors, such as exhaustion, personal risk of infection, fear of transmission to family members, illness or death of friends and colleagues, loss of many patients and long shifts combined with unprecedented population restrictions, including personal isolation [21].

In contrast, a study from Singapore showed a considerably low level of anxiety (8.15%) and depression (14.5%) among HCWs [22]. Different contexts of healthcare systems might have different future plans to encounter sudden outbreaks of infectious diseases depending on the infrastructure availability and policy decisions on healthcare provisions. The COVID-19 was the most devastating pandemic experience for Sri Lankans in the 21st century. Therefore, Sri Lankans did not have prepared for it mentally and did not have adequate insight on strict infection control measures in the early stage of the pandemic. In contrast, in Singapore, the healthcare system and people had faced a similar experience during the SARS outbreak. Therefore, their mental preparedness had been already established to tackle the situation and they had followed strong infection control measures even at the early stages of COVID-19 pandemic [22]. Further, previous working experience in infectious diseases of similar nature that have been encountered in the recent past would have been an added advantage [13, 19]. Therefore, HCWs in different countries have a well-planned agenda of facing a pandemic and prior experience to handle it confidently. This may partially reduce the psychological inconvenience they feel in this type of an outbreak.

The depressive symptoms and anxiety among frontline military professionals were also high in this study. Similar to the HCWs, long working hours, compulsory quarantine rituals, strict hygienic measures, separation from family members, and fear of the family members acquiring the disease could have been the possible reasons for high level of depression and anxiety in this group of people. Apart from these, during the pandemic of COVID-19, contribution of military professionals was totally beyond their usual duties and responsibilities. They were assigned to manage the immediate care centers and quarantine centers, screening of infected and suspected cases from the community and mass vaccination programmes. Further the barracks of military professionals created massive clusters of infection that would have increased their psychological disturbance to a greater extent. Unfortunately, we could not find any similar studies done elsewhere focusing on the frontline military personnel in this context.

The general public reported fewer depressive symptoms and anxiety levels compared to professionals in this study. Similarly, De Boni et al., [17] also reported that general household people had low levels of depression and anxiety. A review [18] reported a lesser prevalence of stress, anxiety, depression, and psychological distress in the general population when compared to HCWs in India [18]. The reasons for less prevalence of anxiety and depressive symptoms would have possibly been due to the poor insight regarding the gravity of the COVID 19 pandemic. As reported in a previous study, in Poland, the individuals infected with SARS-like conditions showed a comparably higher rate of persistent thinking and dysfunctional mental health than non-infected persons during the COVID-19 pandemic. When considering Sri Lanka, this is the first-time people explored the pandemic [23]. Therefore, they have poor insight into the gravity of the disease and its consequences. Therefore, people might have lower levels of anxiety and depression. Studies elsewhere found worsening of a pre-existing psychiatric condition, female gender, occupation or professional engagement, previous exposure to trauma, working remotely and age are associated with higher risks for psychological disturbance, post-traumatic stress disorders (PTSD), and depression due to COVID-19 among the general public [24, 25]. However, we were unable to see any associations except in professional engagement and level of education (low level of education). Different factors revealed in different studies might be related to the sample size and social factors such as prior experience with the pandemics, awareness, psychological status, and support.

This study found significant information about the psychological disturbances among the frontline healthcare and military workforce in Sri Lanka. Mental well-being among this frontline health and security workforce is a determinant factor in the management of many crucial issues in Sri Lanka in the future, similar to the COVID-19 pandemic. Therefore, these findings are important to make a few critical decisions on their health, including all the aspects such as physical, mental, social, and environmental. A long-term plan to resolve such issues and to eliminate this important workforce becoming psychologically ill should be done using these findings as a foundation. Having appropriate mental health programmes, strict epidemic prevention and control policy, community mental health service system, online mental health service, telemedicine, and medical services for them would be a few measures that can be taken to resolve the issue. Due to the non-availability of research findings on military personnel, these findings would be more important to be aware of the psychological disturbances among military personnel who worked at the frontline during the COVID-19 period.

However, this study has a few limitations including, the non-probability sampling approach and fairly a lesser number of participants. The movement restrictions enforced during the study period did not allow a valid method of sampling with more participants. Therefore, this limitation is seen in many other studies done during this period. Further, we did not fit the models for each group since the sub-group analysis did not reveal the significant associations, possibly due to the limited participants in each sub-group. Also, we collected a limited number of essential information during the data collection considering the feasibility during the pandemic. However, the actual psychological burden might influence extraneous variables that has not been addressed in our study. These may limit the generalizability of findings. Therefore, it would be better if a future study considers a more representative sample covering all the areas of Sri Lanka with a reasonably higher number of samples.

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